Recognizing and Treating Depression in Asian Americans

Recognizing and Treating Depression in Asian Americans

There has been phenomenal growth in the Asian American population in recent years. In 1990, there were 7.3 million Asian Americans in the United States, accounting for 3.4% of the population. In 2000, the number increased by 38%, to 10.1 million, or 4% of the US population (2000 census),1 and this growth rate is expected to continue.

Compared with other ethnic groups, Asian Americans underuse mental health services, resulting in delayed treatment and higher attrition rates. A report by the surgeon general2 states that the underutilization is because of the shortage of bilingual services, the low percentage of health care insurance coverage, and the Asian American tradition of using mental health treatment only as a last resort.

Asian Americans tend to first seek help from families, friends, alternative medicine providers, and primary care physicians. Those Asian Americans who do use mental health services tend to have worse short-term treatment outcomes and lower patient satisfaction scores than do white Americans.3

Prevalence
A review of the literature reveals a paucity of published data on the prevalence of mental illness among Asian Americans, both in the community and in primary care settings. Takeuchi and colleagues4 conducted a large-scale community-based study of depression in Chinese Americans living in Los Angeles County using the Composite International Diagnostic Interview.5 They estimated the lifetime prevalence of major depressive disorder (MDD) in Chinese Americans to be 6.9%, much lower than the national estimate of 17.1%.6

Our team examined the prevalence of MDD among Asian Americans in the primary care setting of the South Cove Community Health Center in Boston. South Cove is an urban community health center with wide-ranging clinical services that primarily serves low-income Asian immigrants who face financial, linguistic, and cultural barriers to health care. Using a 2-phase epidemiologic survey, we found the rate of MDD in this population to be 19.6%, which is comparable to or higher than that found in nonminority populations in the United States.

Symptom presentation
In an earlier study, we examined the symptom profiles of Chinese patients with MDD and found that symptoms spontaneously reported by patients differed substantially from those they reported when asked directly about the presence or absence of mood symptoms. Mirroring results found by other researchers,7,8 we discovered that only a small proportion (14%) of patients in this recently immigrated population spontaneously described symptoms from the psychological realm, such as depressed mood, irritability, rumination, and poor memory. A much higher proportion (76%) of patients with depression in this primary care setting presented with physical symptoms as their chief complaint (Table 1). In fact, none of the patients who were depressed in this study considered depressed mood as their chief problem. However, more than 90% of these same subjects endorsed depressed mood when asked to rate their symptoms using a depression rating scale.9

TABLE 1

Chief complaints
of Chinese
patients with
depression (N = 29)

Chief complaint

No. (%)

Physical symptoms

Headache

4 (14)

Cough

2 (7)

Pain

2 (7)

Dizziness

2 (7)

Other

2 (7)

Depressive neurovegetative
symptoms

Insomnia

5 (17)

Fatigue

5 (17)

Depressive psychological symptoms

Irritability

2 (7)

Rumination

1 (3.5)

Poor memory

1 (3.5)

Nervousness

2 (7)

Depressed mood

0 (0)

No complaints

1 (3.5)

In the past, Chinese patients had been thought to be alexithymic (lacking the ability to understand their emotions) or else unwilling to report them. Findings from this study show that the majority of Chinese patients with depression have no problems in either identifying or reporting psychological symptoms.

This was also shown in another South Cove study in 1998, when our team explored the illness beliefs of 29 Chinese American immigrants from a primary care population who were depressed. When the subjects were asked what label they would give their condition, more than half did not ascribe their symptoms to depression or any other psychiatric condition (Table 2). When asked how the symptoms affected them, however, their responses showed an awareness of both an internal psychological state as well as a somatic, physical state. Twenty-six patients (90%) felt that the symptoms affected their mind, and 23 patients (79%) felt the symptoms affected their body, with 22 patients (76%) feeling that the symptoms affected both their mind and their body.

TABLE 2

Labels used by
Chinese patients
with depression
to describe their
illness (N = 29)